Thursday, Dec 20 2012
• 10 a.m. (ET)

Identifying And Treating Severe Mental Illness

The vast majority of mentally ill people are not a danger to themselves or society, but for those who are, treatment is critical. Diane and her guests discuss the challenge of identifying and treating severe mental illness.

Guests

Pete Earley
father of an adult son diagnosed with Bipolar Disorder, author of "Crazy: A Father's Search Through America's Mental Health Madness," former Washington Post reporter and author of several others books, including "The Hot House."

Dr. Liza Gold
clinical professor of psychiatry at Georgetown University Medical Center and vice president of the American Academy of Psychiatry & The Law.

Dr. E. Fuller Torrey
president of Treatment Advocacy Center.

Transcript

10:06:57

MS. DIANE REHMThanks for joining us. I'm Diane Rehm. A blog post titled "I am Adam Lanza's Mother" went viral this week. Thousands of people identified with the author's stark description of what it's like to live with a troubled child and her struggle to get him help. The shooting tragedy at Sandy Hook Elementary is prompting national debate on a number of issues, including what can be done to identify and treat those with severe mental illness.

10:07:35

MS. DIANE REHMJoining me: Dr. E. Fuller Torrey of the Treatment Advocacy Center, Pete Earley, father of an adult son diagnosed with bipolar disorder, Dr. Liza Gold of Georgetown University Medical Center, and Leslie Weisman of the Arlington Community Services Board. Do join us. I know many of you will want to share in this conversation. Call us on 800-433-8850. Send us an email, drshow@wamu.org. Follow us on Facebook or send us a tweet. Good morning to all of you. Thank you for being here.

10:08:22

DR. LIZA GOLDGood morning, Diane.

10:08:22

MS. LESLIE WEISMANGood morning.

10:08:22

DR. E. FULLER TORREYGood morning.

10:08:24

REHMDr. Torrey, I'll start with you. You wrote a piece for The Wall Street Journal published yesterday saying the U.S. would have fewer mass killings of individuals with severe mental illness if individuals with severe mental illness received proper treatment. Tell us what proper treatment, from your perspective, would've entailed.

10:08:57

TORREYWell, the problem, Diane -- and thank you for having us -- is that we have about 7 million severely mentally ill people in the United States today, but half of which are not being treated on it. They are responsible for about half of these mass killings on it. The number of people who are severely mentally ill and dangerous is very small. It would be about 1 percent of all the mentally ill people. These are the people -- so roughly 70,000 people are the people we worry about in the United States. These are the people who often don't know they're sick, so they don't take medication.

10:09:31

TORREYAnd if they're not on medication, then they often act out their symptoms. And their symptoms are usually psychotic symptoms, like delusions and hallucinations, and they act on those symptoms. The fact that we're not treating them because we have closed down most of our beds and because we have some very poor treatment laws and involuntary commitment laws -- Connecticut being a very good example of poor laws -- this is why we're ending up with these kinds of tragedies.

10:09:57

REHMDr. Gold, a number of publications mention the fact that Adam Lanza perhaps had Asperger's. He was autistic. Do those ailments fall into this severe mental illness category?

10:10:19

GOLDWell, they certainly -- Asperger's, not so much, as can be somewhat functionally disabling. Autism can be severely disabling. But there certainly is no association between Asperger's, autism, any of the disorders on the autism spectrum. And this kind of violence that we saw unfortunately and tragically in Connecticut, that is -- if true, it is a coincidental finding and not a finding relative to causation at all.

10:10:52

REHMSo who is considered or what is considered severe mental illness?

10:11:02

GOLDWell, any kind of mental illness can be severe. It's not so much the label or the diagnosis but the intensity and the quantity of the symptoms that a person is experiencing. So an individual can be mildly depressed and still be highly functional, or they can be psychotically in agitated depression with hallucinations and delusions and go out and commit a murder-suicide scenario. So it really isn't the label itself. It's the state of that individual's symptom's acute symptomatology. And as we know with many of these illnesses, symptoms wax and wane.

10:11:43

GOLDSo that someone who is having problems, severe problems today may be feeling better tomorrow. And they may be feeling better just because circumstances change or because they've gotten into treatment, and the treatment is starting to work. But it's not a question of whether they are schizophrenic or delusional. It's really a question of the acuteness of the symptoms and multiple, multiple other factors that go into creating a situation where they could be potentially violent.

10:12:14

REHMLeslie Weisman, do we have any idea of the percentage of those poor labeled mentally ill who may, in fact, hurt themselves or hurt others?

10:12:31

WEISMANWell, in our community, we treat about 3,000 people in Arlington County with serious mental illnesses and as many more people out in our community that we're not serving that are either receiving services privately or they're not availing themselves of services. And of those people we serve, there is approximately 350 people every year in Arlington that we do commit to psychiatric hospitals because they are at risk.

10:12:56

WEISMANThey either are threatening to harm themself or others. So, again, the percentages are very small, but we are routinely assessing for risk for this very reason and looking for the red flag-type of symptoms and behaviors that cause us some concern and make us want to wrap even more intensive services around people to avoid these kinds of outcomes.

10:13:21

REHMIn fact, aren't those with mental illness sometimes more likely to become victims themselves?

10:13:31

WEISMANAbsolutely. These are vulnerable people. These are people that can't always navigate well out in the world. They're disorganized. They're paranoid. They're unsure of themselves. They're hearing voices. And so their ability to get from A to B is often very challenging for them.

10:13:48

REHMPete Earley, talk about your own son who has been diagnosed with bipolar disorder. Talk about your experience with him and trying to get help for him.

10:14:05

MR. PETE EARLEYWell, my son was 22 when he had his first major break, and as Dr. Torrey mentioned, he was one of those who didn't think he was sick. He didn't think anything was wrong. He was delusional. He was talking about suicide. He would cry one moment, and then he'd be laughing the next hysterically. And I rushed him to a hospital in Fairfax County. We were put in a room. We waited four hours. And then the doctor basically came in and said, there's nothing I can do to help your son. There's been no violence.

10:14:35

MR. PETE EARLEYThere's -- obviously, he's not, at the time, the law said, imminent danger to self or others. And the fact we had been sitting there for four hours proved there was no danger. So then I was told, bring your son back after he tries to kill you or kill someone else. I took him home, watched him. At one point, he had tin foil wrapped around his head because he thought the CIA was reading his thoughts.

10:14:55

MR. PETE EARLEYIt was horrible watching as he slipped out of my house -- slipped out of the house early one morning and broke in a stranger's house. Luckily, no one was there. He broke in to take a bubble bath. The police took him out. And all of a sudden, my son became a person who had -- charged with two felonies. And it was just maddening. Virginia law kept me from getting him help when he needed it and now want to punish him for a crime he committed when he wasn't thinking clearly.

10:15:21

MR. PETE EARLEYAnd I discovered it was an aberration. And we really don't have, in my opinion, a mental health system. We -- what we have is a criminal justice system. We have over 600,000 people with bipolar, schizophrenia and major depression in jails and prisons. More than a million go through the system every year. Dr. Torrey has documented that. And so what we're doing is we're turning our mental health problem over to our criminal justice system, trying to fix it that way.

10:15:50

REHMHow often does that happen, Dr. Torrey, that, in fact, the police are brought in rather than a mental health specialist?

10:16:01

TORREYThe police and sheriffs in the United States now, Diane, are the frontline mental health workers, and they know it. And this is not what they signed up for, and they don't like it. Some of them do a very good job, but, remember, they're not trained to do this. Pete Earley is absolutely right. It's very difficult to get care for people who are acutely psychotic and acutely mentally ill in most states because of the way the laws are written.

10:16:23

TORREYThe Treatment Advocacy Center, which I started 14 years ago, has been working to try and change those laws, and anyone who's interested in that -- what the laws are in your state would find our website useful, www.treatmentadvocacycenter.org, all one word.

10:16:38

REHMYou know, it's interesting, Lucinda Roy, the professor from Virginia Tech who counseled as best she could the young man, who ultimately shot many people on that campus, tried to alert Virginia Tech authorities, tried to alert the police, tried to alert mental health professionals, nothing happened. Dr. Gold, what does one do when you have someone with the standing of Lucinda Roy trying to get help and nobody listens?

10:17:23

GOLDWell, it's extraordinarily difficult and frustrating and frightening. They're really -- the way the commitment laws are written -- first of all, you obviously can't force people to -- into involuntary treatment unless they are committed. The way the commitment laws are written, they have a very high threshold for depriving someone of their civil liberties, which is imminent danger to self or others. Although these are legislated on a state-by-state basis, they're all basically quite similar.

10:18:00

GOLDAnd how imminence is defined varies a little bit between state to state but typically is 24 to 72 hours. So if you haven't done -- if the person has not really done something tangible like assault or some other kind of recognizable action that someone might find threatening, it's very difficult to get that person committed.

10:18:26

REHMDr. Liza Gold, she is clinical professor of psychiatry at Georgetown University Medical Center. We'll take a short break here. When we come back, we'll talk more and take your calls.

10:20:05

REHMAnd welcome back. Four people are with me in the studio today. Leslie Weisman, she is client services entry bureau chief at the Arlington Virginia Community Services Board. Dr. Liza Gold is clinical professor of psychiatry at Georgetown University and vice president of the American Academy of Psychiatry & The Law. Pete Earley is the father of an adult son diagnosed with bipolar disorder.

10:20:44

REHMHe is the author of "Crazy: A Father's Search Through America's Mental Health Madness," and Dr. E. Fuller Torrey is president of the Treatment Advocacy Center. His website is at our site, drshow.org. Pete Earley, after your son broke into this home, the police came. Then what happened?

10:21:15

EARLEYWell, they took him to a community treatment center, and I rushed over. And a policeman was waiting outside, and he said, listen, Mr. Earley, even though your son has told us he has bipolar disorder, even though he's told us he's off his medication, even though we picked him up in a house taking a bubble bath, unless you go in and you tell the psychiatrist in there that your son has tried to kill you, he will not go to a treatment center. He will go to jail. And I said, well, my son hasn't done that. And he said, listen, if you don't want him in jail, you need to say that. And I went in, and I lied.

10:21:46

EARLEYAnd it hurt my relationship with my son, but that was good enough to get him into the hospital where he voluntarily committed. Twenty-four hours later, the insurance company called. They wanted him out. They said he was not dangerous. And I actually called -- I was fortunate enough to be friends with Mike Wallace of "60 Minutes," who suffered from depression. And Mike called that insurance company, and, all of a sudden, my son was allowed to stay in the hospital. Amazing. But in the short time between my son's breakdown to get him in the hospital, I had lied to get him into treatment.

10:22:18

EARLEYI had violated my oath, bullying people, using my sources. But what -- you know, Dr. Gold just said that the commitment process is difficult. Dangerous standard is difficult. But there's also such a lack of services. Diane, the inspector general in Virginia just released a report that said 70 people who met the dangerousness criteria are -- were turned away from Virginia hospitals because there was no beds for them.

10:22:47

EARLEYAnd, you know, when I did my research -- Fairfax County, one of the richest counties in the United States. When I did my research, there was a two-week wait to get into a treatment program, a six-month wait to get a case manager and an 18-year wait to get into any kind of housing program. That's shameful. That's what's crazy.

10:23:09

REHMAnd, Dr. Torrey, you have your own personal experience with an individual mentally ill.

10:23:18

TORREYYes, indeed. My sister had schizophrenia. She died two years ago, which she had schizophrenia for over 50 years. So I saw the -- how these services either work or don't work from the 1950s on. It's a very broken system. I think Peter Earley just described really how broken the system is and how difficult it is to get treatment for people who are severely mentally ill. It's a question of not having any beds.

10:23:42

TORREYWe basically closed down 95 percent of the beds that were available half a century ago, and the laws in most states are written very badly. For example, in Connecticut, they're among the worst laws in the United States, so that if, in fact, this -- Mrs. Lanza had tried to get help for her son, we don't know whether she did or didn't, if she tried to get help for her son, this would've been one of the worst states to try and get help in.

10:24:03

REHMWhat do you mean?

10:24:04

TORREYThe way the laws are written. The laws are written so that the person has to be overtly dangerous to be treated at that time. And Connecticut is one of only six states that does not have an outpatient treatment commitment order. Five other states -- all other states, except Connecticut and five others, have such orders.

10:24:20

REHMWould we have fewer mass killings if there were better mental health services?

10:24:29

TORREYAbsolutely. We would have about half the number we're having now because half of them are caused by severely mentally ill people who are not being treated. Some of these are preventable. The Loughner killings in Tucson were preventable. The killings in Aurora, Colo. almost certainly were preventable if there had been adequate treatment available.

10:24:47

REHMDr. Gold, do you agree?

10:24:49

GOLDWell, I agree -- I don't know about half. But certainly, these are not people who are chronically homicidal. These are -- when -- they are mentally ill individuals committing these acts. They have warning signs right and left that they are becoming unstable and violent with the understanding that nobody can predict the future and that even people with high-risk factors -- high violence assessment risk factors, may not become violent and people with no evident risk factors may suddenly become violent.

10:25:21

GOLDWe do have very good systems for evaluating the various factors that go into creating an individual with high risk. And the more of those factors that you can identify, the more places you have to intervene. And those violence risk assessments are commonly taught, well-disseminated among the mental health professional population. We know how to recognize many of these, and we know how to intervene.

10:25:48

GOLDThe problem is as we are saying that we have two issues. One is we don't have the resources, and the other is we don't have the legal standing to contain someone to try to treat them. But if you could do that and get these people through the moments of crises when they might reach for an assault weapon, then we could prevent some of these killings.

10:26:13

REHMLeslie, help me to understand your role in all of this.

10:26:21

WEISMANWell, our role as a community mental health center in Virginia and particularly my role is to operate a crisis intervention center where we are the front door to mental health services in our community for people with serious mental illnesses. And our goal is to be as accessible and available as we can possibly be not only to serve these people but to provide information to the community.

10:26:44

REHMAll right. So let's take a, for example, had Adam Lanza's mother called you or walked into your door, what would you have done if she had said, I fear my son is dangerous?

10:27:04

WEISMANWell, what we would have done was we would've immediately tried to ascertain where he was so that we could go and assess him. If we have a family member come in and tell us that they feel at risk, they don't feel safe, we will go out in our community. We don't wait for people to come to us. Many people, of course, with serious mental illness don't want treatment. So we have to reach out.

10:27:26

WEISMANIn our community, we work extremely closely with law enforcement. We have provided CIT, Crisis Intervention Team training to our law enforcement officers for five years now. We've trained 181 officers and provided specialized mental health skills. We would have gone out to her home to assess her son and to determine what types of services he needed.

10:27:48

REHMPeter Earley.

10:27:49

EARLEYOne of the problems is that we have a patchwork system. What happened in Arlington, what was just described is exactly what should happen. What happened to my son in Fairfax is exactly what shouldn't happen. I had written a book. I had spent three years studying this. I'm not a stupid person. I understood the system. But when my son had a break and he became dangerous, I called Fairfax Country crisis response team.

10:28:14

EARLEYThey said, well, is he dangerous, or is he violent? I said, he's violent, and they said, oh, we can't come. Call the police. And the police came and shot my son with a taser, hogtied him and took him away. Now, this is part of the problem. Fairfax Country, it's almost impossible to get someone involuntarily committed. In another jurisdiction, it's not. And that's representative across the United States. These laws are applied differently, and services, whether they're available or not, make a huge difference on whether a person is actually going to get help.

10:28:47

REHMHow long was your son hospitalized?

10:28:52

EARLEYWell, and that's the other problem. You think, oh, wow, if I can get somebody and voluntarily committed, wow, I'll really get this problem -- I can get something done. And Virginia, the average length of involuntary commitment is five days, unless a person that gets extremely, extremely violent, and then you may get 30 days. But there are no beds.

10:29:14

REHMNo beds.

10:29:15

EARLEYNo. Right now -- that's what I, you know, we're turning people away. There was a Virginia -- a University of Virginia study done that estimated that 2,400 people who needed emergency care in Virginia, which I pick on 'cause it's my state, would not receive any services just because there weren't any places to take him. There are no beds. You can spend four hours in Virginia looking for a bed.

10:29:41

REHMDr. Torrey, is this the situation pretty much around the country?

10:29:46

TORREYIt's all over the country. It's worse in some states than other states. There's no state that I would recommend now as opposed to 30 years ago that has good services. They've all gone downhill. Remember, we had at one time 559,000 beds for these people in the United States. We have less than 43,000 now with a population that's almost twice as great. So we basically have one out of 20 beds that we had available 50 years ago.

10:30:10

TORREYAnd as Pete Earley says, there's simply nowhere to send them. Even in Virginia, people often have to wait several hours in emergency rooms, have to be taken to cities that are 100, 200 miles away to find a bed at all. The states have done the same. They're going to save money. They don't save money at all, of course. It costs more in the long run to treat these people.

10:30:30

REHMDr. Gold.

10:30:31

GOLDYes, that's absolutely true. And, in fact, when you do actually have -- meet all the legal standards to get someone committed, it may be much more difficult to find a bed to hospitalize that person than to get that person committed, even if you have someone who's clearly meeting the standards for commitability. So it's a problem. There are less than 20 beds per 100,000 people in the United States available, psychiatric beds, and once you get them in, the length of stay now has been so reduced -- remember, most psychiatric medications take two to six weeks to have maximum effect.

10:31:09

GOLDSo if you're discharging people after three days, four days, five days, and you don't discharge them to a community -- to adequate community services, which, as we're hearing across the board here, do not -- are minimal and, in some places, do not exist. Arlington is an exceptionally good system in my experience. I live in Fairfax County. I've worked both in Fairfax County and in Arlington, and I would say that you've got almost the two ends of the spectrum here with exceptionally good services and exceptionally limited...

10:31:43

REHMBad response.

10:31:44

GOLD...limited services and even bad responses in Fairfax County. And it's a very difficult situation for families to be in because no one wants to call the police on their family member for a variety of reasons. On the other hand, when these folks do become violent, often the majority of the victims of the violence are family members, and so they're not safe either. So it's a horrible crisis.

10:32:13

GOLDAnd the fact that there are no step-up containment centers, a place where someone could be for 24 hours or 48 hours without being actually committed or hospitalized, a place, for example, for residential treatment for young adults who can't live at home, don't need to be in the hospital but need a structured environment, all of these were the sort of community-based services that were supposed to be funded when we emptied the psychiatric hospitals and deinstitutionalized the populations.

10:32:42

GOLDDr. Fuller certainly can speak more to this probably than I can, but those things were never funded to the extent that was required to maintain safety.

10:32:51

REHMDr. Liza Gold. And you're listening to "The Diane Rehm Show." Dr. Torrey, take us back to the closing down of the psychiatric institutions. St. Elizabeth's here in Washington stands out as one of the ones that sort of shuttled us into this age of deinstitutionalization.

10:33:25

TORREYIt all started after World War II, and basically the belief was that these people could live in the community. They didn't really need anything. There wasn't anything very wrong with them and that the state psychiatric hospitals were terrible places. So, basically, what we did very effectively is we emptied out the hospitals. What we didn't do is provide the services for the people who left the hospital.

10:33:46

TORREYYou've got to remember, Diane, about half of these people who came out of the hospital have damage to their brain in a way that they can't appreciate the fact that they're sick, so that they don't voluntarily reach out for services. They don't think there's anything wrong with them. These are the people that are most difficult to treat. These are the people for whom you need good commitment laws, and you need beds available. We don't have either one. So this is 50 years later of a very badly thought through social strategy, and now we're paying the prices for it.

10:34:15

REHMIf you could wave a magic wand, what would you do now?

10:34:21

TORREYI would do two things. I would say that each governor and state legislature is responsible for these people, and we're going to hold them responsible when you go to the polls. Number two, I would ask for some federal leadership, which we're getting none. And the Department of Health and Human Services, we have no one in the health -- Department of Health and Human Services who has any interest in this problem, and that's why there's been no federal leadership at all.

10:34:44

REHMPete Earley, tell us about your son after he was released from the hospital.

10:34:51

EARLEYWell, we went through numerous painful, painful years, just heartbreaking, and then finally had another break. This time he took off because he didn't want to be tasered by the police, but he came back. He ran off to North Carolina, but then he came back. He went into a safe house. He ended up getting hospitalized, but here's what's really great: He got a case manager who worked with him, and she insisted the hospital keep him until he got stable.

10:35:27

EARLEYThen he got doctors. Believe it or not, Diane, I -- my son's had seven psychiatrists over the years. Only two have bothered to learn anything but his name and his symptoms because we're telling them that, you know, all you have to do is stick a pill in somebody's mouth and you're going to get paid for 15 minutes and that's it. And you have to treat the whole body when you treat the mind, you know?

10:35:46

EARLEYAnd she got him a doctor who actually listened to him and said, why don't you like to take medications? What are the symptoms? Let's work -- and so she worked with him. Then she got him into a transitional housing, so he could live. They said, you know, living with your dad is probably not the best thing for you. So he got into that. And then she said, what do you want to do with your life? And she got him into peer-to-peer training.

10:36:06

EARLEYAnd now my son is paid to go and help other people with mental illnesses and do things like take -- he worked with somebody who had been in a basement for years, afraid to come out, and get those people out, get them into the community, help them get their life back. So when people say to me, you can't recover, they're wrong. I've seen it happen. I -- my son is the example of that.

10:36:32

REHMHow old is he now, Pete?

10:36:34

EARLEYHe's 33.

10:36:35

REHMAnd still working?

10:36:37

EARLEYStable. Stable for six years. He has two jobs. He has his regular job, and then he works part-time because he wants to get out. One of the biggest problems with -- that people with mental illness face is isolation. You know, I was in San Francisco. I talked to a woman who's panhandling. She actually came from a wealthy family. I said, why do you panhandle? It's the only way I can get people to talk to me. That's the kind of isolation these people have.

10:37:02

REHMAnd the fact of the matter is if the psychiatric wards, as we once knew them, are now closed -- if Pete Earley had not had Mike Wallace's help, he might not have gotten the help he needed for his son -- we are facing a true crisis in this country. We're going to take a short break here. We're having some problems with our phones. I hope we can work in some calls.

10:40:05

REHMAnd here's our first email from Roger in Virginia. He says, "I have an adult daughter with a mental illness normally kept under control by medications. In this post-Sandy Hook debate, some say it's all about the mentally ill. Others say it's all about the guns. I say it's about a lethal combination of the two." Dr. Gold.

10:40:38

GOLDYeah. I've referred to this in the past few days in other venues as a perfect storm because you've got the lack of mental health resources that we've been discussing. You've got the limited means for legal intervention due to the limited commitment laws. And then when these folks are in moments of crisis, they have access to weapons that can cause a maximum amount of damage in a minimal amount of time. So to say that guns are not a part of it is -- both arguments would be false.

10:41:15

GOLDIt is a perfect storm where someone who is acting out in the throes of an agitated delusional state has access to something that can cause a horrific tragedy. If you take a knife -- if one person takes a knife and tries to stab a number of people, that's also a tragedy. I'm not minimizing that at all. It's not going to do the kind of damage or cause the kind of body count that you get with someone with an assault rifle with a clip that has 30 automatic rounds. So that's a huge piece of this that also has to be addressed.

10:41:51

REHMDr. Torrey.

10:41:53

TORREYWell, I think Dr. Gold is absolutely right. It is both. It's not either or. It's both a gun problem and a mental illness problem, and the combination is really, really terrible. It's important to realize that this is increasing. We are not -- we're seeing an increasing number of these, both in terms of homicides and in terms of the mass killings. And until we actually do something, this is going to continue to increase. We're going to be back here another three months or another six months talking about the same problem.

10:42:19

REHMAll right. To South Hampton, N.Y. Good morning, Deborah.

10:42:24

DEBORAHGood morning, Diane. How are you?

10:42:26

REHMI'm fine. Thanks.

10:42:28

DEBORAHI am calling because I'm the mother of a 15-year-old child who has been diagnosed for -- in the past two years and with bipolar. And she has been hospitalized five times. Every time they would release her after no more than three weeks, saying that she was hospitalized. Meanwhile, she had continued to hurt herself. She had continued by cutting, by burning herself, until the fifth time. She actually attempted suicide. And then and only then she was able to be on a long-term treatment at a state psychiatric hospital for children, the only one there is.

10:43:16

DEBORAHAnd even then, she had to wait for two months in the hospital where the insurance would not pay her stay. And that state hospital saved her life. And there is only one. I -- it is mind-boggling to me, the financial and the psychological destruction that it just brings on their families and these people. My daughter used to say, I am worth nothing. I keep getting back to the hospital. There is no hope for me. Meanwhile, she did not understand that she kept going to the hospital because they didn't address her danger to herself.

10:44:05

REHMI'm so sorry, Deborah, about your daughter. It makes me wonder whether what happened at Sandy Hook is likely to change anything or whether, as Dr. Torrey has said, God forbid, we may be back here in three months talking about this all over again. Pete Earley.

10:44:29

EARLEYWell, I'd like to be optimistic. But let's look at Virginia again. After the Virginia Tech shooting, everyone went, oh, we got to do something. And we did. We modified our law, and the legislators passed $42 million in new programs, which was fantastic. The next year, they cut $50 million from the mental health budget. And this, you know...

10:44:51

REHMI'm sitting here with my mouth falling over.

10:44:52

EARLEYNo. You know, and I'm very fearful. There's others here who'll better understand this than me, but passing gun control laws may not impact the budget as much, I can guarantee that, as trying to fix our mental health system. And when it comes to spending money, especially now we're going off a fiscal cliff, I'm very pessimistic that anything will happen.

10:45:18

REHMDr. Torrey.

10:45:20

TORREYWell, New York State, fortunately, has a assisted outpatient treatment law, so somebody who's been stabilized five times in the hospital and then falls apart when they leave the hospital, one of the questions that come to my mind is whether they're staying under medication and whether they're being adequately medicated on it. But New York State does have a law that says you can live in the community as long as you take your medications, and that sometimes is very helpful.

10:45:42

TORREYMedications themselves are not sufficient. They're necessary, but as Pete Earley has very clearly described and Leslie is describing also, you need rehabilitation facilities. You need housing. You need all the other things that go along with it. But if you don't have a system where they're staying on stable medication, the others won't work.

10:45:59

REHMI want to go now to Miami, Fla. Good morning, Jamie.

10:46:05

JAMIEHello. How are you?

10:46:06

REHMFine. Thank you.

10:46:09

JAMIEI was calling in just to echo what the gentleman said about Virginia, specifically Fairfax County. I'm 43 now, and I've been struggling since the age of 18 when my father had a break. I eventually had to go to court -- that's when they wanted to become his guardian, to fight to get him any kind of help. In the end, we finally got him help, although we begged and pleaded because we feared for him, we feared for everybody, the neighbors. He had a highly armed house. We still couldn't get any help.

10:46:36

JAMIEFinally, when he threatened a neighbor, to kill him that day, we were able to get the police to come. It was a horrific scene. My daughter -- or my sister and I had to lure him out of the house so that they could capture him. Just like the other gentleman said, it was a terrible scene. And it's just been a terrible, terrible fight for the last 25 years. And it's a combination of gun control, the lack of insurance for these folks who still need it and then the mental health attitude in this country, I guess, for getting the proper care in advance in a proactive way rather than retroactively.

10:47:10

REHMJamie where is -- excuse me, where is your father now?

10:47:15

JAMIEHe's still in Fairfax County.

10:47:17

REHMHe's still in Fairfax County. Leslie.

10:47:23

WEISMANWell, again, every community is vastly different. And it brings us back to the early discussion around both relationships between mental health and law enforcement and the obligation, in my opinion, of community mental health agencies to reach out to the community and to educate them.

10:47:38

WEISMANYou know, there's a lot of red flags that had been raised in the last year or so around individuals that we need to be paying particular attention to, and it falls not only to community mental health agencies but to schools, to parents to religious organizations, to law enforcement to be having a conversation together around mental health, around what services are available, how to access them, how to best provide them and how to reach out to people that don't want help. What is the best way to do that?

10:48:08

REHMDr. Gold.

10:48:09

GOLDYes. And one of the really heartbreaking things -- and I don't know if this is the case in the Sandy Hook shooting -- is that so many of these folks who've been involved in these shootings, they have either been referred for help or have had parents who've wanted to try to help them. The list is endless. The Virginia Tech shooter actually had an outpatient commitment that wasn't worth the paper it was printed on because it wasn't enforced.

10:48:37

GOLDSo it's not that these are people who popped out of the woodwork and there was no indication typically, I can't speak generally, but there are warning signs. There are warning signs, then -- and if enough different institutions provide a safety net and communicate about a safety net, much of this can be prevented. Not all, nobody has a crystal ball or can see the future. But these are not people who just suddenly wake up and decide they're going to go out and shoot people.

10:49:06

REHMSo, Dr. Torrey, President Obama's focus yesterday with Vice President Biden chairing what they say is going to be a short-term study ending in January on how to mitigate cutback on gun violence. Your fear would be what?

10:49:32

TORREYMy fear is that a month from now, people will be less interested, and it will end up with some minor gun control measures but will do nothing to really fix the underlying problem. We have to make sure that people understand that the state officials, the governor, the legislature, the people who are in charge of the state mental health system, ultimately they are responsible and they have to be held responsible for these terrible conditions.

10:49:56

REHMYou've said that Connecticut has one of the worst mental health programs. What states have the best?

10:50:06

TORREYYou know, once upon a time, 30 years ago, I could have told you states like New Hampshire -- it's not that the mental health program in Connecticut generally is terrible. The programs are pretty reasonable. The problem is the laws. They have among the worst laws in the United States. There is not a single state now that I can say has a good mental health system. Anybody who wants to look at a good mental health system now has to go to Northern Europe. There is nothing in United States that is really of good quality.

10:50:33

REHMThis is an interesting email from Jennifer. "Why not have a required mental health evaluation similar to the required physicals? It could be a simple screening before entering kindergarten, middle school, high school and college. If a problem is detected, there could be a referral. This could help to eliminate the stigma. It would also be covered by insurance just as our physical health is." Pete Earley, what's your reaction?

10:51:16

EARLEYWell, of course, one of the problems with mental illness is it's diagnosed by the symptoms. And we have two doctors here who can speak to that much better than I can. So I think one of the things you had to understand is these are very complex illnesses. My son has been diagnosed as bipolar disorder, schizoaffective, schizophrenia, and the diagnosis often is done through medication. Oh, lithium worked. He must be bipolar.

10:51:40

EARLEYThese are hard to figure out. I'm all for trying to identify emerging mental illnesses especially in young people. I think that this incident, if it does anything, may help educate the public that you don't have to be in your 20s or 30s to have a mental illness or to have a mental problem. How you do that is going to take the expertise of the doctors, not a parent. I'm not quite sure how you do that.

10:52:06

REHMYeah. So if you got a young man like Adam Lanza who is quiet. He is -- he does look people in the eye. He simply keeps to himself. I mean, what does that tell us other than that he wants to be alone?

10:52:28

GOLDWell, it doesn't necessarily tell us much. What you also want to look at is changes. Is that how he's always been? Is that a change in his interactional abilities? Is there a change in his functioning? Is there a change in his behavior? So you want to put all of those pieces together to see if this is someone that you maybe want to prod a little a bit to see if you can figure out what's going on in his head.

10:52:55

REHMAnd you're listening to "The Diane Rehm Show." Pete Earley, would you have taken your son to a gun range to teach him how to shoot?

10:53:10

EARLEYI grew up in the Wild West, and I had guns, and I used to hunt until I married my wife. And she said there will be no guns in this house. And my -- and as a matter of fact, my son, who has a mental illness, was someone who enjoyed shooting at camps and things like that. I don't have guns in the house.

10:53:28

EARLEYAnd I know that the research I've read suggests that if you have guns in the house and you have mental illness in the house, there's a higher chance that that gun will be used in a suicide than in an attack. But, again, I'm with Dr. Torrey on this and that the underlying problem is the mental illness. And in his piece in The Wall Street Journal, he pointed out that you can kill someone with a knife, too. It's just the amount of people that you can harm.

10:53:54

REHMOf course, the other issue or the medications themselves. Some of those can actually be dangerous, Dr. Torrey.

10:54:05

TORREYWell, of course, and we don't want to overmedicate some patients, and especially children have been overmedicated on it. But by in large, if you have a psychotic illness, these are the best medicines we have, and they are reasonably safe. They are safe as medicines we use for cardiac care. But if you're overprescribed, if you're overmedicated, if you're not treated by somebody who knows what they're doing, yes, you can have side effects, and they can be dangerous.

10:54:27

TORREYOne other thing in terms of screening children, it's important to remember that most people with severe mental illnesses are not sick at 5 years old or 6 years old. These are diseases that come on in the late teens and early 20s.

10:54:39

REHMSo that's when they tend to show up with the kinds of symptoms we're talking about.

10:54:45

TORREYThat's correct. Most people with schizophrenia and bipolar disorders start between 16 and 30.

10:54:51

REHMHow is the Affordable Care Act likely to affect the kind of health people may or may not get, Dr. Gold, Dr. Torrey?

10:55:06

TORREYIt is -- it will provide some experiments in the states that will be useful. For example, there's an exclusion. Medicaid cannot be used for state hospitals now. And in some states, it will allow for experiments to see, if we changed the funding system, will that improve things? I think that's one of the most important things that the Obamacare will do.

10:55:26

GOLDAnd I would add that just to the...

10:55:28

REHMGo ahead.

10:55:28

GOLD...just to the extent that at that very vulnerable age, between 18 and 26, just to extend insurance to the extent that insurance is useful. And we can all agree, I think, that it's not as useful as it could be.

10:55:44

REHMBut Medicaid?

10:55:45

GOLDRight. But that parents -- but kids can stay on their parents insurance till 26.

10:55:51

REHMRight.

10:55:51

GOLDThat's a very vulnerable age group, and I think that that may also -- again, it increases resources in -- from that aspect.

10:56:01

REHMDr. Torrey, give us your Web address again.

10:56:05

TORREYwww.treatmentadvocacycenter.org, all one word. Lots of information available for families that are having trouble finding treatment.

10:56:14

REHMAnd, Pete Earley, what would you say to a listener as to how best to find help for a loved one?

10:56:25

EARLEYWell, first of all, you had to become an advocate, then make yourself aware of groups like the National Alliance on Mental Illness, which is the largest grassroots organization, so you can get help from other parents. Get a good psychiatrist. But most of all, give your son and yourself hope. People with mental illness can and do get better. Most people can if they get the right kind of help, but you have to fight hard to get it.

10:56:49

REHMPete Earley, the father of an adult son diagnosed with bipolar disorder, he is the author of "Crazy: A Father's Search Through America's Mental Health Madness." Dr. Liza Gold of Georgetown University, Leslie Weisman of the Arlington Virginia Community Services Board, and Dr. E. Fuller Torrey, president of the Treatment Advocacy Center. Let's hope we have been of help this morning. Thank you, all. Thanks for listening. I'm Diane Rehm.

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